Gynecomastia: Ultrasound-Confirmed Classification Pertainent to Surgical Correction.

BACKGROUND: Gynecomastia is the most common form of breast alteration in men, due to proliferation of the gland ducts and stromal components, including fat. In addition to the most obvious indications (weight loss, pharmacotherapy, and drugs suspension), the surgical treatment is needed for long-standing gynecomastia, combining liposuction, adenectomy, partial mammary adenectomy, periareolar skin resection, and round-block suture. MATERIALS AND METHODS: A retrospective study was conducted on 148 patients undergoing gynecomastia correction from May 2012 to April 2018. Follow-up ranged from 9 to 14 months. The authors propose a new ultrasound-confirmed classification system, dividing patients into six categories. The authors analyzed immediate complications, revision, recurrence, and minor aesthetic problems (retracted/depressed areas) and introduced a way to correct the irregularities with fat grafting and needles. RESULTS: The total complication rate was 11.5% (17/148). Most of the complications (11) were observed in patients who underwent glandular resection and 3 after liposuction only. Retrospective surveys about patients' and surgeons' satisfaction were performed, showing excellent feedbacks regarding the results accomplished. CONCLUSIONS: The simple classification helps surgeons choose the most suitable approach, avoiding insufficient or invasive treatments and undesirable scars. Moreover, the analysis of the type of sequelae and their correction allow high patients' satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Dorsal Augmentation with Diced Conchal Cartilage Wrapped in Retroauricular Fascia.

BACKGROUND: Dorsal augmentation is of primary importance to shape an ideal nose. Although costal cartilage is still used for this purpose, diced cartilage grafts wrapped in autogenous fascia became more and more popular in recent decades. In this paper, the authors report their experience with a new combination made by diced conchal cartilage wrapped in retroauricular fascia in primary and secondary cases. METHODS: The clinical records of the first 19 patients to undergo dorsal augmentation with this technique were reviewed. The entire concha has been harvested and, once diced, wrapped in a sleeve of retroauricular fascia obtained using the same incision. Quilting reabsorbable sutures closed the mastoid dead space and prevented the risk of hematoma. The graft has been used in all the cases through a closed approach. CONCLUSION: The use of diced cartilage is nowadays considered one of the best options among the available procedures for dorsal augmentation. Diced conchal cartilage wrapped in posterior auricular fascial graft is a new, simple and safe procedure that eliminates the necessity of a secondary donor site (temple or thorax), speeds up the operation and leaves a well-concealed scar behind the ear. Its main disadvantages toward costal diced cartilage wrapped in rectus abdominis fascia are the minor quantity of cartilage that can be obtained, even in case of bilateral harvest, and compared to temporal fascia a longer postoperative swelling (6-8 weeks). LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Stenotic Breast Malformation and Its Reconstructive Surgical Correction: A New Concept From Minor Deformity to Tuberous Breast.

BACKGROUND: Several classification systems have been reported to define the spectrum of tuberous breast deformity, and a range of surgical techniques has been described. In this paper, we proposed a new classification including tuberous breast and minor deformity based on stenosis type, glandular trophism and ptosis adapting surgical planning to different breast types. METHODS: A total of 246 patients meeting our definition for stenotic breasts asking for surgery were analyzed in this study. We considered eight different types of stenotic breasts analyzing anatomical presentations, and we then proposed eight key-point maneuvers, finalized to the correction of different breast deformities and their possible association according to the stenotic breast type. Results have been evaluated by a group of three surgeons and by patients. In addition, we evaluated the complication incidence in terms of re-intervention rate. RESULTS: Following our classification eight different groups were distinguished. For each one we reported the prevalence and the surgical procedure adopted. Results evaluated by the surgeon group reported a mean aesthetic outcome of 8.2 (range 5-10), whereas patients reported a mean value of 7.9 (range 6-10). During a follow-up period with a mean of 16 months we observed a 4.9% re-intervention rate. CONCLUSIONS: We believe this new classification to be very complete in evaluating breast shape, including most of the breast evaluable features. Our results confirmed the suitability of the approach for appropriate preoperative planning, thus improving the global surgical outcome. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Periareolar Approach in Oncoplastic Breast Conservative Surgery.

Breast cancer represents the most frequent cancer in female population. Nowadays breast conservative surgery (BCS) is an accepted option for breast malignancies, and its indications has been extended thanks to the advent of oncoplastic surgery, reducing both mastectomy and re-excision rate, avoiding at the same time breast deformities. From January 2008 to November 2011, 84 women underwent BCS with periareolar approach for oncoplastic volume replacement. We divided patients into four groups analyzing breast size and resection volume (Group 1: small-moderate sized breast with resection <20%; Group 2: small-moderate sized breast with resection >20%; Group 3: big sized breast with resection <20%; Group 4: big sized breast with resection >20%). We evaluated patients' satisfaction regarding final esthetic outcome using the specific module "Satisfaction with outcome" of the Breast-Q questionnaire 1 year after surgery. The mean age was 52.1 years, and the mean follow-up was 11.2 months. During the follow-up, 12 patients have been lost. We obtained high satisfaction mean value with Breast-Q questionnaire in each group: 75.8 in group 1, 63.4 in group 2, 81.1 in group 3, 69.7 in group 4. Periareolar approach as oncoplastic volume replacement technique is useful in correction of breast deformity after BCS: it is a versatile technique that can be easily adapted for any breast tumor location and for wide glandular resection.

The Prevalence of Tuberous/Constricted Breast Deformity in Population and in Breast Augmentation and Reduction Mammaplasty Patients.

BACKGROUND: The exact prevalence of tuberous breast deformity (TBD) has not been properly investigated and still remains undetermined. We report our data about TBD prevalence with the aim of demonstrating its high prevalence. MATERIALS AND METHODS: A retrospective analysis was performed on preoperative photographs of 1600 Caucasian female patients admitted to our department from January 2009 to July 2014 for augmentation or reduction mammaplasty and other breast clinical conditions. The main features of TBD included a contracted skin envelope, a reduction in breast parenchyma of the lower medial and lateral quadrants, a constricted breast base, abnormal elevation of the inframammary fold, herniation of the breast into the areola with a constricted breast base, and nipple areola complex herniation with a normal breast base. Patients were classified into three groups: breast augmentation group (AUG group), breast reduction group (RED group), and general population group (POP group). RESULTS: Four hundred patients were analyzed for each group (AUG and RED group); 194 patients (48.5 %) and 189 cases (47.3 %), respectively, demonstrated at least one tuberous breast deformity; in 800 patients of the POP group, we found 221 patients (27.6 %) with at least one tuberous breast deformity. CONCLUSIONS: Retrospective analysis reveals a high prevalence of TBD in the general population and in particular in women seeking breast augmentation or breast reduction (about 50 %). TBD is characterized by a wide range of clinical features with a spectrum of degrees. Preoperative evaluation is crucial to achieve an optimum outcome and patient satisfaction. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment of chronic headache of cervical origin with lipostructure: an observational study.

OBJECTIVE: To test feasibility, safety, and efficacy of local transplant of stromal fraction of adipose tissue in the treatment of chronic headaches of cervical origin. BACKGROUND: Chronic headaches of cervical origin (chronic cervicogenic headache and occipital neuralgia) are characterized by persistent pain due to the involvement of the great occipital nerve, with concurrent myofascial spasm and the consequent nerve entrapment within the trapezoid tunnel. METHODS: Tolerability and effectiveness of treatment of chronic cervicogenic headaches refractory to conventional therapies were evaluated in 24 patients. The visual analog scale of pain and the medication use diary were used in the 3 months preceding treatment; moreover, in order to verify the quality of life, patients are required to fill before surgery the neck pain disability index, the headache disability index, migraine disability assessment scale questionnaire, and the short-form 12 standard v1 questionnaire. Follow-up examination was performed at 3 and 6 months. RESULTS: In 19 cases (79.2%), a good clinical response was recorded. At 6-month follow-up analysis, recurrence of occipital pain was recorded in 7 cases (29.2%); there is a significant reduction in disability and pain scores, and also a significant reduction of need for pharmacologic treatment and a fast return to previous work capacities. CONCLUSIONS: The key point of our therapeutic strategy might be the regenerative role of stromal fraction of adipose tissue transplanted in the area of the occipital nerve entrapment; the results of the present study are encouraging both in terms of reduction of pain scores and in terms of quality of life improvement. The technique is minimally invasive, and no complications were recorded; indeed, the procedure seems to be safe and effective, and thus, a randomized study with larger follow-up and in a large series will be started.

Autologous fat graft in scar treatment.

INTRODUCTION: Regenerative medicine is an emerging and rapidly evolving field of research and therapy, thanks to new discoveries on stem cells. Adipose tissue is a connective tissue which contains a reserve of mesenchymal stem cells. Clinical improvements in trophic characteristics of teguments after autologous fat graft are well described in literature. In this paper, we present our observation after 6 years of autologous fat graft experience in scar remodeling. MATERIALS AND METHODS: All patients recruited had retractile and painful scars compromising the normal daily activity/mobility of the joint involved. We performed surgical procedure with Coleman technique. In 20 patients, we performed a clinical assessment using Patient and Observer Scar Assessment Scale (POSAS) and Durometer measurements. RESULTS: In all treated scars, a qualitative improvement was shown both from an aesthetic and functional point of view. Most importantly, reduction or complete resolution of pain and increases in scar elasticity were objectively assessable in all cases. In patients studied using Durometer and POSAS score, areas treated with autologous fat graft showed statistically significant reduction in hardness measurements in comparison with areas infiltrated with saline solution. POSAS scores showed a statistically significant reduction of a great deal of POSAS parameters as a result of an improvement of both clinical evaluation and patient perception. CONCLUSIONS: Injection of processed autologous fat seems to be a promising and effective therapeutic approach for scars with different origin such as burns and other trauma scars, and post-surgery and radiotherapy outcomes. In general, we can affirm that treated areas regain characteristics similar to normal skin, which are clinically objectivable, leading not only to aesthetic but also functional results.

Efficacy of short-term antibiotic prophylaxis in immediate two-stage breast reconstruction after mastectomy: A retrospective monocentric study.

BACKGROUND: Infective complications following implant-based breast reconstruction range from 2,5 to 24% and are often associated with high morbidity and poor outcome. Many authors still employ long-term antibiotic prophylaxis even though there is no conclusive evidence on the impact on infection-rate reduction. In the present study, we report we report our single-shot short-term prophylaxis protocol for surgical site infection prevention in immediate two-stage implant breast reconstruction. METHODS: We retrospectively compared clinical data from two groups of women undergoing immediate two-stage breast reconstruction with tissue expander. Group 1 (n = 391) was administered with long-term prophylaxis, and Group 2 (n = 89) was administered with short-term prophylaxis associated with early drains removal (21 days maximum). We evaluated risk factors for infection, clinical preoperative data, time before drain removal, and clinical feature of the diagnosed infections (early or late onset) and compared the reconstructive outcome between the two groups (infection rate, implant loss rate). RESULTS: We did not find any statistically significant difference in the infection rate (11,51% overall) and implant loss rate (4,49% overall) between the two groups. We found a difference in the implant loss to infection ratio (46.67% in group 1 and 20% in group 2, p < 0,05) and in the time before drain removal (19 days in group 1 and 15 days in group 2, p < 0.001). We finally found an association between prolonged time before drain removal and increased infection rate (p = 0.004). CONCLUSIONS: Short-term single-shot perioperative antibiotic prophylaxis associated with early drain removal (within 21 days postop) represents a safe approach in terms of prevention of local infective surgical complication and allows a more effective treatment of the diagnosed SSI.

The Periareolar Approach: All Seasons Technique for Multiple Breast Conditions.

The periareolar approach was first introduced by Hollander in 1924 and, since then, numerous contributions have been reported by different authors. Despite all the strengths associated with this versatile technique, the periareolar approach still poses three main problems: large areolar diameter with poor quality scar, flattening of the breast cone, and poor stability of the results. The purpose of this article is to show how this surgical technique, with a good patient selection, can be applied to different situations and obtain excellent results. METHODS: We performed a retrospective study on 5028 consecutive procedures in 4198 female patients treated with a periareolar approach in two regional institutions between 2008 and 2018. We considered 853 pure mastopexies, 362 breast augmentations, 422 secondary breast augmentations, 402 corrections of stenotic breast, 2921 oncoplastic surgeries, and 68 breast reductions. Postoperative complication, as well as patient and surgeon satisfaction were assessed. RESULT: Patient and surgeon satisfaction 1 year after the procedure was excellent, and the complication rate was low. CONCLUSIONS: When the indication is set correctly, the periareolar approach can obtain excellent results. This versatile technique, initially introduced as a mastopexy technique, has expanded its applications and can now be used for multiple surgical situations.

Aesthetic and Functional Abdominoplasty: Anatomical and Clinical Classification based on a 12-year Retrospective Study.

Abdomen reshaping is a common plastic surgery procedure, and numerous surgical techniques have been described in the scientific literature. To standardize surgical approach, we propose our protocol that correlates patients' anatomy with the type of procedure performed. METHODS: Between 2008 and 2020, we retrospectively analyzed 582 consecutive female patients who underwent abdomen reshaping procedures, assessing anatomical features, complication rate, patient satisfaction, and surgical result, comparing them with previous reports in the literature. Aesthetic outcomes were evaluated with VAS scale (0-10). RESULTS: Among the 582 patients recruited in the study, we performed 74 liposuctions as a single procedure, 62 mini-abdominoplasties, 28 T-inverted abdominoplasties, and 418 full-abdominoplasties. Aesthetic outcome evaluation reported a mean value of 8.2 from patients and 7.8 from surgeons. We experienced four early postoperative bleedings requiring hemostasis revision, 18 wound dehiscences, five seromas, and 24 re-interventions for aesthetic issues. We found no differences in the complication rate while comparing our data with previous reports in the literature. CONCLUSIONS: Our protocol and surgical technique have proved to be effective, safe, and reproducible, with high patient and surgeon satisfaction, low complication rate, and fast recovery time.

Breast Reconstruction in a Coronavirus Disease 2019 Hub.

The coronavirus disease 2019 (COVID-19) pandemic presented a dramatic challenge to healthcare systems. Humanitas Clinical and Research Hospital (Rozzano, MI, Italy) was declared a regional hub for the treatment of COVID-19 patients. Our plastic surgery team, in consultation with our breast surgery colleagues, decided to perform immediate implant-based breast reconstruction for patients undergoing mastectomy for cancer. In this report, we present our experience performing breast reconstruction with a new protocol in the first month following the COVID-19 pandemic in the most affected region in Italy. METHODS: We adopted a new protocol to treat patients with breast cancer during the COVID-19 pandemic. The main goals of our protocol were to reduce the risk of COVID-19 spread for both patients and clinicians, postpone nononcologic and more advanced surgery, develop rapid recovery for early patient discharge (within 24 hours from surgery) through pain management, and finally reduce postoperative consultations. RESULTS: The protocol was applied to 51 patients between early March and early April 2020. After 1 month, we decided to retrospectively review our experience. We found no significant differences in terms of postoperative pain and complication rate compared with our data in the pre-COVID period. CONCLUSION: Our new protocol is safe and effective, enabling tumor resection and immediate implant-based breast reconstruction, without increasing risks to the patient or staff.

Superior Pedicle Breast Reduction with Prefiguration of Final Shape: A 10-year Retrospective Study.

Breast reduction, also defined as reduction mammaplasty, is one of the most common procedures performed in aesthetic surgery. Multiple techniques have been proposed throughout the years and several classification systems have been adopted according to: type of incision, pedicle blood supply (cutaneous, glandular, dermoglandular), extent of undermining, excision area, simultaneous or separate tissue excision (fat/gland, skin, or both), and combination of the aforementioned. In the present article, we share our 10 years' experience with reduction mammaplasty and we describe our personal technique, a modified superior pedicle breast reduction. METHODS: We performed a retrospective analysis on 823 consecutive patients undergoing either aesthetic or functional reduction mammaplasty at Humanitas Research Hospital between 2009 and 2018. For each patient, we evaluated the mean resection volume and complication rate. We also assessed patients' satisfaction (VAS scale) and aesthetic outcome (assessed by independent surgeons, scale from 1 to 5). RESULTS: The average patient age was 48, ranging from 17 to 77 years. The average operative time was 77 minutes, ranging from 62 to 123 minutes. After a thorough follow-up of these patients, we can conclude that our technique has a low complication rate, patients' satisfaction is excellent, and the result is stable over time in terms of shape and symmetry (the mean VAS score was 8.1). Postoperative surgeon's photographs evaluation scores were 4.5 ± 0.5. Average resected volume was 860gr. CONCLUSION: The proposed technique is safe, fast, and simple with a relatively short learning curve, making it didactic and intuitive for young surgeons.

Fat Grafting for Treatment of Facial Scars.

Autologous fat grafting has become more and more popular among plastic surgeons in the last few years due to recent discoveries on the mesenchymal stem cells stored in the harvested fat. These cells have a great regenerative potential and have the ability to restore the damaged tissues. The authors focused their practice on the treatment of the facial scars (derived from burns, trauma, degenerative diseases, and radiotherapy) and confirm that lipofilling is an excellent solution because it is able to improve the quality of the damaged tissues in terms of better scar color, pliability, thickness, relief, itching, pain, scar vascularization, and pigmentation.

Regenerative Approach to Scars, Ulcers and Related Problems with Fat Grafting.

The article focuses on the authors' autologous fat grafting technique and its application in regenerative treatment of different scars and ulcers. Although easy to perform, this surgical approach requires some technical procedures and specific management to maximize its effectiveness which are highlighted in the article. In the authors' experience, autologous fat graft has proved to be an efficient and safe procedure to treat scars of different origin demonstrating the capability of lipostructure to achieve an architectural remodeling and loose connective regeneration.

Autologous fat graft as treatment of post short stature surgical correction scars.

INTRODUCTION: Surgical limb lengthening is undertaken to correct pathological short stature. Among the possible complications related to this procedure, painful and retractile scars are a cause for both functional and cosmetic concern. Our team has already shown the efficacy of autologous fat grafting in the treatment of scars with varying aetiology, so we decided to apply this technique to scars related to surgical correction of dwarfism. A prospective study was conducted to evaluate the efficacy of autologous fat grafting in the treatment of post-surgical scars in patients with short-limb dwarfism using durometer measurements and a modified patient and observer scar assessment scale (POSAS), to which was added a parameter to evaluate movement impairment. PATIENTS AND METHODS: Between January 2009 and September 2012, 36 children (28 female and 8 male) who presented retractile and painful post-surgical scars came to our unit and were treated with autologous fat grafting. Preoperative and postoperative mean durometer measurements were analysed using the analysis of variance (ANOVA) test and POSAS parameters were studied using the Wilcoxon rank sum test. RESULTS: There was a statistically significant reduction in all durometer measurements (p-value <0.05) and in all but one of the POSAS parameters (p-value <0.05) following treatment with autologous fat grafting. DISCUSSION: Surgical procedures to camouflage scars on lower limbs are not often used as a first approach and non-surgical treatments often lead to unsatisfactory results. In contrast, our autologous fat grafting technique in the treatment of post-surgical scars has been shown to be a valuable option in patients with short-limb dwarfism. CONCLUSION: There was a reduction of skin hardness and a clinical improvement of all POSAS parameters in all patients treated. Moreover, the newly introduced POSAS parameter appears to be reliable and we recommend that it is included to give a more complete evaluation of patient perception.